1. How to read a CTG?
Dr Pradeep S
Dr Sabitha US

2. Looking at the CTG paper systematically
Check the name, identity number
Check the time and the date
Define risk and the indication of CTG monitoring
Check the maternal pulse, temperature
Drugs if any- pethidine, betamethasone, MgSo4, methyl dopa, betamimetics
Epidural?
Intrapartum care: NICE guideline CG190 (December 2014).

3. Intrapartum care: NICE guideline CG190 (December 2014).
Overall care
Do not make any decision about a woman's care in labour on the basis of cardiotocography (CTG) findings alone.
Take into account:
any antenatal and intrapartum risk factors, the current wellbeing of the woman and unborn baby, and the progress of labour when interpreting the CTG trace. –
Remain with the woman at all times in order to continue providing one-to-one support.
Ensure that the focus of care remains on the woman rather than the CTG trace. Make a documented systematic assessment of the condition of the woman and the unborn baby (including CTG findings) hourly, or more frequently if there are concerns.
Intrapartum care: NICE guideline CG190 (December 2014).

4. Check your paper speed first
1cm/minute
3cm/minute
Intrapartum care: NICE guideline CG190 (December 2014).

5. Intrapartum care: NICE guideline CG190 (December 2014).

6. Intrapartum care: NICE guideline CG190 (December 2014).
Classification of CTG
Normal
Non Reassuring
Abnormal
Intrapartum care: NICE guideline CG190 (December 2014).

7. Interpretation- 4 features
Baseline
Variability
Accelerations
Decelerations
Intrapartum care: NICE guideline CG190 (December 2014).

8. Baseline FHR - Definition
The mean level of the FHR when this is stable, excluding accelerations and decelerations. It is determined over a time period of 5 or 10 minutes and expressed in bpm.
The normal baseline FHR varies between bpm (slightly quicker for preterm).
A baseline FHR of bpm or bpm is non-reassuring.
A baseline FHR of <100 or >180 bpm is classified as an abnormal feature.
Intrapartum care: NICE guideline CG190 (December 2014).

9. Intrapartum care: NICE guideline CG190 (December 2014).

10. Observed over 5-10 minutes Prematurity associated with higher FHR
Baseline rate - Mean level of FHR (excluding accelerations and decelerations)
Observed over 5-10 minutes
Prematurity associated with higher FHR
Trend in baseline and absolute value important
Normal
bpm
Non-reassuring
Borderline tachycardia bpm
Borderline bradycardia bpm
Abnormal
Tachycardia >180bpm
Bradycardia <100bpm
Intrapartum care: NICE guideline CG190 (December 2014).

11. Baseline fetal heart rate
usually be between 110 and 160 beats/minute
between 100 and 109 beats/minute with normal baseline variability and no variable or late decelerations is normal and should not prompt further action
between 90 and 99 beats/minute with normal baseline variability may be a normal variation; obtain a senior obstetric opinion if uncertain.
Intrapartum care: NICE guideline CG190 (December 2014).

12. Intrapartum care: NICE guideline CG190 (December 2014).
between 161 and 180 beats/minute with no other non-reassuring or abnormal features on the cardiotocograph:
think about possible underlying causes (such as infection) and
appropriate investigation check the woman's temperature and pulse
if either are raised, offer fluids and paracetamol start one or more conservative measures
Intrapartum care: NICE guideline CG190 (December 2014).

13. Intrapartum care: NICE guideline CG190 (December 2014).
Tachycardia>160BPM
Normal BPM
Bradycardia<100BPM
Intrapartum care: NICE guideline CG190 (December 2014).

14. Intrapartum care: NICE guideline CG190 (December 2014).
Tachycardia
160/min
Intrapartum care: NICE guideline CG190 (December 2014).

15. Intrapartum care: NICE guideline CG190 (December 2014).
Causes
Hypoxia Chorioamnionitis Maternal fever
B-Mimetic drugs Fetal anaemia,sepsis
Heart failure, arrhythmias
Intrapartum care: NICE guideline CG190 (December 2014).

16. Intrapartum care: NICE guideline CG190 (December 2014).
FETAL BRADYCARDIA
Bradycardia
100 bpm
Intrapartum care: NICE guideline CG190 (December 2014).

17. Intrapartum care: NICE guideline CG190 (December 2014).
Baseline variability
The minor fluctuations in baseline FHR occuring at three to five cycles per minute.
It is measured by estimating the difference in beats per minute between the highest peak and lowest trough of fluctuation in a one-minute segment of the trace
Variability between 5 and 25 bpm is considered ‘reassuring’. Reduced variability of <5 bpm can be physiological during periods of fetal sleep.
Intrapartum care: NICE guideline CG190 (December 2014).

18. Variability Normal > or = 5 bpm between contractions Non-reassuring
<5 bpm for 40 minutes or more
(but less than 90minutes)
Abnormal
<5 bpm for 90 minutes or more
Intrapartum care: NICE guideline CG190 (December 2014).

19. Intrapartum care: NICE guideline CG190 (December 2014).5
Intrapartum care: NICE guideline CG190 (December 2014).

20. Intrapartum care: NICE guideline CG190 (December 2014).
5 Beats above and 5 beats below
1 minute
Intrapartum care: NICE guideline CG190 (December 2014).

21. Intrapartum care: NICE guideline CG190 (December 2014).
Accelerations
An acceleration is a transient increase in FHR of at least 15 bpm above the baseline which lasts for at least 15 seconds .
Presence of FHR Accelerations have Good outcome.
Absence of accelerations on an otherwise normal CTG remains unclear.
Intrapartum care: NICE guideline CG190 (December 2014).

22. Intrapartum care: NICE guideline CG190 (December 2014).
Accelerations
Normal
2 accelerations in a 20 minute trace “reactive”
Accelerations less frequent in active labour
Intrapartum care: NICE guideline CG190 (December 2014).

23. Intrapartum care: NICE guideline CG190 (December 2014).
15 beats
15 seconds
Intrapartum care: NICE guideline CG190 (December 2014).

24. Intrapartum care: NICE guideline CG190 (December 2014).
Decelerations
A deceleration is a transient decrease in FHR of at least 15 bpm below the baseline which lasts for at least 15 seconds.
The presence of decelerations is a non-reassuring or abnormal feature in a CTG and is classified according to the type, duration and frequency of the decelerations.
Intrapartum care: NICE guideline CG190 (December 2014).

25. Intrapartum care: NICE guideline CG190 (December 2014).
Decelerations
When describing decelerations in fetal heart rate, specify:
the depth and duration of the individual decelerations
their timing in relation to the peaks of the contractions
whether or not the fetal heart rate returns to baseline
how long they have been present for
whether they occur with over 50% of contractions.
Intrapartum care: NICE guideline CG190 (December 2014).

26. Intrapartum care: NICE guideline CG190 (December 2014).
Decelerations
Describe decelerations as 'early', 'variable' or 'late'. Do not use the terms 'typical' and 'atypical' because they can cause confusion. [new 2014]
Intrapartum care: NICE guideline CG190 (December 2014).

27. Intrapartum care: NICE guideline CG190 (December 2014).
Decelerations
15 sec
15 beats
Intrapartum care: NICE guideline CG190 (December 2014).

28. Intrapartum care: NICE guideline CG190 (December 2014).

29. Early Vs Late Deceleration
Early Deceleration
Late Deceleration
Intrapartum care: NICE guideline CG190 (December 2014).

30. Intrapartum care: NICE guideline CG190 (December 2014).
Early deceleration
Caused by head compression
Intrapartum care: NICE guideline CG190 (December 2014).

31. Intrapartum care: NICE guideline CG190 (December 2014).
Late deceleration
Intrapartum care: NICE guideline CG190 (December 2014).

32. Intrapartum care: NICE guideline CG190 (December 2014).

33. Intrapartum care: NICE guideline CG190 (December 2014).

34. Intrapartum care: NICE guideline CG190 (December 2014).
Late Deceleration
Must be uniform in both length and depth; for this reason true late decelerations are uncommon (more commonly they are atypical variable decelerations that have been wrongly classified)
Late decelerations are one feature of uteroplacental insufficiency.
Intrapartum care: NICE guideline CG190 (December 2014).

35. Variable deceleration
vary in length and amplitude and are not uniform (unlike early and late decelerations).
Typical
'Shoulders' (primary and secondary acceleratory phases)
Atypical
Overshoots
Loss of primary shoulder/acceleratory phase
Smooth deceleration
Slow return to baseline (late component)
Baseline returns to a lower level (after deceleration)
Biphasic (W shape)
Intrapartum care: NICE guideline CG190 (December 2014).

36. Typical variable deceleration
'Shoulders' (primary and secondary acceleratory phases)
Intrapartum care: NICE guideline CG190 (December 2014).

37. Atypical deceleration
Intrapartum care: NICE guideline CG190 (December 2014).

38. Intrapartum care: NICE guideline CG190 (December 2014).

39. Intrapartum care: NICE guideline CG190 (December 2014).
Sinusoidal pattern
A regular oscillation of the baseline long-term variability resembling a sine wave. This smooth, undulating pattern, lasting at least 10 minutes, has a relatively fixed period of 3–5 cycles per minute and an amplitude of 5–15 bpm above and below the baseline. Baseline variability is absent
Associated with -
Severe chronic fetal anaemia
Severe hypoxia & acidosis
Intrapartum care: NICE guideline CG190 (December 2014).

40. Intrapartum care: NICE guideline CG190 (December 2014).
SINUSOIDAL
Intrapartum care: NICE guideline CG190 (December 2014).

41. Intrapartum care: NICE guideline CG190 (December 2014).
PSEUDOSINUSOIDAL
Intrapartum care: NICE guideline CG190 (December 2014).

42. Intrapartum care: NICE guideline CG190 (December 2014).
SALTATORY PATTERN
Intrapartum care: NICE guideline CG190 (December 2014).

43. Intrapartum care: NICE guideline CG190 (December 2014).

44. Intrapartum care: NICE guideline CG190 (December 2014).

45. Definition of, normal, non reassuring and abnormal ctg
Normal CTG: no non-reassuring or abnormal features, healthy fetus
Non reassuring: Combination of features that may be associated with increased risk of fetal acidosis; if accelerations are present, acidosis is unlikely
Abnormal: likely to be associated with fetal acidosis
Intrapartum care: NICE guideline CG190 (December 2014).

46. 2007 nice categorisation of ctg

47. Intrapartum care: NICE guideline CG190 (December 2014).
Latest Categorisation of ctg
Intrapartum care: NICE guideline CG190 (December 2014).

48. Intrapartum care: NICE guideline CG190 (December 2014).
Description
Baseline
(beats/ minute)
Baseline variability (beats/ minute)
Decelerations
Non reassuring
161–180
less than 5 for 30– 90 minutes
Variable decelerations:
-dropping from baseline by 60 beats/minute or less and
- taking 60 seconds or less to recover,
- present for over 90 minutes
- occurring with over 50% of contractions OR
-dropping from baseline by more than 60 beats/minute or taking over 60 seconds to recover
- present for up to 30 minutes
– occurring with over 50% of contractions OR
Late decelerations:
present for up to 30 minutes
occurring with over 50% of contractions
Intrapartum care: NICE guideline CG190 (December 2014).

49. Intrapartum care: NICE guideline CG190 (December 2014).
Description
Baseline
(beats/ minute)
Baseline variability (beats/ minute)
Decelerations
Normal
100–160
5 or more
None or early
Intrapartum care: NICE guideline CG190 (December 2014).

50. Intrapartum care: NICE guideline CG190 (December 2014).
Abnormal
Baseline
(beats/ minute)
Baseline variability (beats/ minute)
Decelerations
Non reassuring
Above 180 or below 100
Less than 5 for over 90 minutes
Non-reassuring variable decelerations (see row above):
still observed 30 minutes after starting conservative measures
occurring with over 50% of contractions OR
Late decelerations
present for over 30 minutes
do not improve with conservative measures
Bradycardia or a single prolonged deceleration lasting 3 minutes or more
Intrapartum care: NICE guideline CG190 (December 2014).

51. Intrapartum care: NICE guideline CG190 (December 2014).
Record keeping
Make sure that date and time clocks on the cardiotocograph monitor are set correctly label traces with the woman's name, date of birth and hospital number or NHS number, the date and the woman's pulse at the start of monitoring.
Keep cardiotocograph traces for 25 years and, if possible, store them electronically.
In cases where there is concern that the baby may experience developmental delay, photocopy cardiotocograph traces and store them indefinitely in case of possible adverse outcomes.
Intrapartum care: NICE guideline CG190 (December 2014).

52. Intrapartum care: NICE guideline CG190 (December 2014).
Thank you
Intrapartum care: NICE guideline CG190 (December 2014).